By Emma Opthof, Center for Health Care Strategies
For individuals who live in rural or otherwise underserved regions of the country, lack of access to primary and specialty health care services can be a significant barrier to addressing health needs. Sanjeev Arora, MD, a liver disease specialist from the University of New Mexico, recognized this gap and created Project ECHO in 2003 to expand access to care for people with Hepatitis C across the state. The ECHO Model, which has since expanded its clinical focus and geographic reach across the nation and the globe, virtually connects community providers with specialists to help deliver best practice care to patients.
To test the applicability of this model in improving care for Medicaid patients with complex health and social needs, the Center for Medicare and Medicaid Innovation supported a pilot for ECHO Care, which integrates the ECHO Model with the ambulatory intensive care unit (aICU) approach to complex care teams. The Playbook Team recently spoke with Miriam Komaromy, MD, FACP, DFASAM, former associate director of the ECHO Institute and ECHO Care lead, to learn more about the ECHO Care pilot, which involved 770 patients from 2013 to 2016. Dr. Komaromy, who is currently the medical director of the Grayken Center for Addiction at the Boston Medical Center, shared key takeaways from the recent evaluation of the ECHO Care intervention to help inform other complex care programs.
Q: How does ECHO Care combine the unique characteristics of the aICU model with the ECHO model?
A: The aICU’s goal is to bring all of the necessary components of care to the patient rather than using a care manager or nurse to coordinate the services that are typically offered across multiple settings. In this care model, you have a whole team (which we called an outpatient intensivist team) that is attempting to meet patient needs as best as possible, including primary care, behavioral health care, and the engagement and navigation services of a community health worker.
Acknowledging that it takes significant technical knowledge to manage the complex combination of physical, behavioral, and social challenges that these patients have, the idea behind ECHO Care was to build a structure in which multiple medical and behavioral health specialists came together every week by videoconference, heard the patient cases presented by the outpatient intensivist teams, and offered their expertise to help manage the patient conditions.
Q: What are the implications of the recent evaluation of the ECHO Care model for the broader field of complex care?
A: It's clear from the literature that we're still trying to figure out the best way to care for patients with complex health needs and social barriers. Noting that the evaluation of ECHO Care was not a randomized controlled trial (RCT), we did see a tremendous impact of ECHO Care on decreasing hospitalizations and emergency department visits, and we used a variety of techniques to try to ensure that our results didn't just reflect regression to the mean.
We did not achieve clear cost reductions, but it was evident that patients were more satisfied with ECHO Care than with usual care. We've all just seen the outcome from the RCT of the Camden Coalition’s complex care model, and appreciate that RCTs represent the gold standard for demonstrating impact. That said, our model was different from theirs in several ways – we took the aICU approach, had the input of specialists through ECHO Care, and included many patients in highly rural areas. I think it would be worth performing a randomized trial of something similar to our model with the benefit of knowing what we learned in controlling costs without sacrificing care quality. There are a number of things we would have done differently with 20/20 hindsight that I think could have reduced the cost of the care, such as less staff at the outset as the program ramped up, automatic referrals from the managed care organizations, and including individual specialists in weekly consultations only on an as-needed basis. The ECHO Care program was quite expensive because we had so many specialists involved. Throughout the pilot, the biggest specialist roles were played by the psychiatrist, the counselor, and the addiction specialists — the folks who were addressing incredibly complex and pressing behavioral health and addiction problems. That was often the most urgent thing to get control of and what the teams needed a tremendous amount of help with.
Q: Complex care has lately been heavily emphasizing the need to address behavioral and social needs, but the Camden Coalition’s RCT reminds us of how medically complex these high-need, high-cost populations are. What is the value of focusing on the medical complexity? How did this play out in ECHO Care?
A: For ECHO Care, it was quite shocking how sick many of our patients were and how little support they had in managing such challenging medical conditions. Through the project, we realized that we had to adjust our expectations away from cure and more to mitigation. We could help to improve the quality of life for patients, but we probably weren't going to fully treat their severe medical issues. I wish that we had a way of tracking longevity, because I think there were many instances in which we clearly intervened in situations where the patient may have died without the intervention of the teams and the specialists backing them up.
We also learned that the medical expertise has limited value if you don't first get a certain amount of control over mental illness and substance use. Patients can’t properly manage their diabetes or prevent the worsening of kidney failure if they're actively struggling with a behavioral health issue.
For the Camden Coalition’s program, I don’t think that the six-month evaluation time frame was long enough precisely because of medical complexity. It probably took a long time for patients to develop all of their complex problems, and it takes a long time to address them effectively. If you don’t take the time to engage with a patient and earn their trust, you will not succeed in helping to improve their situation. If the evaluation time frame is too brief, then you won’t see the major benefits start to accrue.
Q: How important is patient engagement in the ECHO Care model?
A: Many patients were afraid to come out and interact with the world, often because of a history of trauma, which was pronounced in more rural areas. Figuring out how to literally get in the door was often the real challenge, but you also had to be cautious about overwhelming the patient. You feel like there's a three alarm fire going on because their kidneys are getting worse and you're afraid they're going to end up in renal failure, but if you throw too many suggestions and interventions at the patient at once, they're going to back off and refuse to engage. You can control the medical issues and potentially reduce costs, but you can't get there unless the patient overcomes their distrust of the medical system, agrees to come out of their house, and get the tests that are needed.
To build that initial trust, you have to understand what matters to the patients and what their goals are. We used the ECHO videoconferencing sessions to provide mentoring support to the care teams and address those basic questions: How do you talk to a patient who's been traumatized? How do you work with a patient who believes that the health care system is out to get them and isn't to be trusted? What are the baby steps that you can take to connect with this mostly alienated patient population and start working with them?
Q: Can you give an example of a specific patient story illustrating the benefits of the ECHO Care model?
A: One patient, a Spanish-speaking laborer in Southern New Mexico, had become ill, unable to work, and homeless. He had a lot of chronic medical problems, but also a lot of trauma. When he would take his medication, he was able to control his blood pressure and blood sugar and avoid hospitalizations. But when he stopped taking those medications, his blood pressure would get out of control, his kidneys would worsen, his heart would worsen, so there was a whole cascading effect. He wasn’t willing to come into the office — he was very skittish and didn't want to interact with the health care system. The team would go out looking for him and they would find him, but they were frustrated because he wouldn’t sit down and talk with them, so they didn’t know how to get him his medication.
The discussion in the ECHO Care session landed on the solution of bringing him lunch and simply eating with him on a regular basis so the team could engage him in casual conversation about his medications. They brought him lunch regularly and he ended up doing much better through this connection. Although this routine was very unconventional, it was the key to getting a handle on some of his issues and preventing hospitalization.
Q: There is increasing recognition that implementing complex care management programs in rural regions has its own unique challenges. How did this play out in piloting the ECHO Care model?
A: New Mexico is an incredibly poor state and patients often didn't have a vehicle or couldn't afford gas to get to a medical appointment even if they wanted to, so the teams would go out for home visits. It involved a fair amount of travel and occasionally included the medical and behavioral health providers going out, not just the nurse and community health worker.
Being willing to do the legwork in finding the patient, going out to the trailer in the distant hills, knocking on the trailer door, and navigating around the ferocious dog . . . all of that stuff was just part of the deal. This ended up being successful in engaging people in their own care who were both physically remote and emotionally isolated. The patients were often very touched by the fact that teams were willing to find them and work with them in their home.